Death leads to improved speed of blood delivery

The death of an 82-year-old woman after a procedure to inspect her heart has sparked improvements at a hospital.

Joan Eveline Jaggard, from Bracknell, died at Royal Berkshire Hospital in Reading on Thursday, November 24, last year.

She was admitted with a heart attack on Monday, November 21, and had an angiogram on Wednesday, November 23.

Speaking at an inquest into her death on Tuesday, Dr Charlie McKenna, consultant cardiologist, said he had performed 10,000 such procedures.

He said: “These circumstances were extremely unusual and very unfortunate – it rarely proves fatal.”

The procedure was described as ‘uneventful’ but the following morning Mrs Jaggard experienced a drop in blood pressure and became unresponsive although attempts were made to raise it, the inquest at Reading Civic Centre heard.

Dr McKenna said: “We never really got to the stage where she was stable in any way but after an hour and 10 minutes the decision was made to use type O blood.”

However, because type O was “not readily available” there was a delay.

Dr Jonathan Fielden, chief medical officer at Royal Berkshire NHS Foundation Trust, said: “It usually arrives within five to 15 minutes and that timescale was not achieved, but in this case it would have made no difference.”

Mrs Jaggard had a long history of angina, hypertension and chronic kidney disease and when the procedure was performed her artery was “almost like concrete”, which meant blood leaked.

In a statement, Dr Dipak Kotecha, cardiology specialist registrar, said he saw the patient on Thursday, November 24, at 10.30am and recorded a large volume of blood in her abdomen.

Dr McKenna said: “If she had not have had the problems with her heart, she may have survived.”

Coroner Peter Bedford recorded a narrative verdict and said the agiogram was the “appropriate procedure” but her heart had “extensive damage” and was unable to cope.

He said the delay in getting the blood to Mrs Jaggard was “of concern” but in this case “availability would not have made any difference to the outcome”.

He told Mrs Jaggard’s family that the benefits from the death would be a change in procedures at the hospital. The case will be used as a scenario to run through in simulations and the hospital is improving how quickly it gets blood to patients.